PART 1: AN INTRODUCTION TO RELIGION & HEALTH CARE

Young Americans are also becoming more outspoken about religion. An ongoing study of U.S. college students shows that a full 83% are affiliated with some religious denomination, and 70% say that religion is an important part of their lives. Forty percent say it is important to follow religious teachings in their everyday lives. These young religious people are not only becoming our patients, but also our colleagues.

RELIGIOSITY Among Western nations, the United States is one of the most deeply religious, if not the most deeply religious. Studies consistently show that around 90% of Americans believe in a God, and 75% of us characterize our outlook on life as "somewhat religious" or "very religious." Only 16% report having a "largely secular" outlook, meaning that religion is not a major factor in their day-to-day lives. Religious beliefs are not always private and personal, either. Almost one-half of Americans report talking to co-workers about religion at least weekly and more than one-half say that religion has a role in interactions with colleagues and the decisions made at work. More significantly for health care providers, 41% of Americans report that religious beliefs have directly influenced a health care decision they’ve made for themselves or a loved one. As all these trends continue, America’s diversity—religious, cultural, and otherwise —will continue to increase. Being a competent provider in this multicultural world increasingly requires that practitioners understand how to navigate the diverse beliefs and practices of their patient populations.

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Not Just Religion: Spirituality and Patient Care

While some researchers are assessing the power of religious beliefs and/or spirituality to impact healing, this manual does not address those questions. As such, our goal is neither to promote nor to denigrate the power of religion and spirituality, but rather to emphasize how they can affect patient decision making and how this may require practitioners to reconsider how they respond in order to ensure the best health outcomes. Thus, this manual affirmatively takes the position that practitioners should not promote or impose religion or spirituality on a patient, but rather that they should be alert when it is playing a role in the patient’s health care and respond appropriately. Given the foregoing, much of this manual deals with what are commonly called “organized religions” and how practicing those religions can affect health care decisions. Our focus has not been on what is commonly defined as spirituality. Nonetheless, it is important to acknowledge that spirituality, both within and outside of organized religion and its beliefs, is also important in the lives of many people. How individuals manifest spirituality is as individual as how they might manifest their religion; both spiritual and religious practices can influence decisions and compliance

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with medical treatment. It is as important for providers to recognize this component of personal identity and how it can affect patient care as it is to understand the laws of kashruth or halal.

DEFINING OUR TERMS: RELIGION AND SPIRITUALITY Although the words “religion” and “spirituality” are often used interchangeably, they actually refer to two different concepts. Most of this manual focuses on organized religions, that is, belief systems with agreed upon components: sacred texts, doctrines, deities, and practices. All religions may not include every one of those components, but they have at least some element or tradition that is widely shared among fellow believers in the particular religious community or denomination. For example, Shintō has no holy books, but has agreed upon beliefs, rituals, and holidays. Native American religions differ widely from tribe to tribe, but each has a world-view and concept of humanity’s relationship to nature. Islam, Judaism, Christianity, and Sikhism have sacred texts, shared beliefs, and shared rituals. In contrast, “spirituality” typically refers to one’s personal relationship to a higher power, to others, or to the world. As opposed to the tenets of organized religions, which exist independently of any individual believer, spirituality is even more highly individualized. Because it is so self-directed and is not bound by any agreed upon religious principles, it is also flexible: A person can be both religious and spiritual (e.g., a committed Christian who attends church follows the tenets of Christianity and also meditates individually to deepen his/her relationship to God), or spiritual but not religious (e.g., someone who believes in some higher power but does not subscribe to any particular religion’s view concerning that power). Personal spirituality may be a completely internal experience, or may influence a person’s actions and behavior. It can also be totally secular. A person may not believe in any kind of divine higher power, but may find comfort, support, and meaning in a range of practices including meditation, music, or running.

WHAT DOES SPIRITUALITY LOOK LIKE? Because it is so highly individual, spirituality can look like anything at all—or nothing. Personal spirituality may involve prayer, meditation, or yoga. It can include specific rituals or behaviors that have roots in a religious tradition or that are unique to the person. There may be outward manifestations, like keeping a vegetarian diet, or no discernible signs at all.

WHAT DOES THIS MEAN FOR PROVIDERS? Although varieties of personal spirituality are vast, understanding patients’ needs comes down to the same respectful communication needed when discussing more overtly religious topics. In theory, discussing spirituality is no different from discussing religion. After all, all adherents of a particular religion don’t believe and practice in exactly the same way —no two Hindus or Sikhs practice their faiths identically—and good communication is required to understand each person’s particular needs. Thus, practitioners need to talk to their patients to understand whether and to what extent spirituality has meaning for them, their sources of strength, how they cope, and whether there are particular

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practices or observations that are important to them that might impact their health care behaviors or decision making. The spiritual assessment tools suggested in this manual are deliberately broad so that they apply to discussions of religion and/or personal spirituality. Here are a few of the questions that will be more important when discussing personal spirituality:

 What gives your life meaning?

 What are your sources of hope?

 Do you have any beliefs or practices that help you cope with stress?

 Does faith or belief have any importance in your life?

 Are there any spiritual practices you have that I, as your health care provider, should know about?

Reading through some spiritual assessment tools will give you more ideas for ways to have these conversations.

ONE TOOL: THE RELAXATION RESPONSE Among the groundbreaking work in this area is the research of Dr. Herbert Benson of Harvard Medical School, who uses a tool called the Relaxation Response to reduce stress (which is increasingly being associated with any number of medical conditions and is known to exacerbate illness and delay healing). Although the Relaxation Response is useful for any patient, religious, spiritual, or atheist/agnostic, we discuss it here because it may be of particular use for non-religious or spiritually inclined patients who do not have a religious community, rituals, or prayer upon which they rely for comfort or stress relief. The relaxation response is a “physical state of deep rest that changes the physical and emotional responses to stress... and the opposite of the fight or flight response.”3 Studied and outlined by Dr. Herbert Benson of Harvard Medical School, one of the pioneers in researching the mind-body relationship, the Relaxation Response is a calm, stress-free state brought about by a simple meditation on a word or phrase. Dr. Benson has established that a reduction of stress can improve healing, bringing about better health outcomes. According to Benson, the key elements needed to invoke the Relaxation Response are:

A Quiet Environment Ideally, the patient should be in a quiet, calm environment with as few dis- tractions as possible; this may not always be possible for hospitalized or bed- ridden patients. A calm setting also makes it easier to eliminate distracting thoughts. For a religious or spiritual person, this might be a religious setting.

3 Benson H. The Relaxation Response. New York: HarperTorch; 1976, p. 4.

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A Mental Device A constant, repetitive stimulus—a sound, word, or phrase repeated silently or aloud—is used to focus the mind and helps to remove the patient from focusing on everyday thoughts. One of the major challenges for eliciting the Response is that the mind wanders, and repetition of a word or phrase helps break through those distracting thoughts. Attention to the rhythm of breath- ing is also useful. A religious person may choose a word related to his/her faith. A non- religious but spiritual person or an atheist or agnostic may select a word that has personal meaning or a random word used only for meditation purposes.

A Passive Attitude This is the most important element needed to create the Relaxation Response. When distracting thoughts occur, the patient is instructed not to dwell on them, returning instead to the repetition of the mental device.

A Comfortable Position A comfortable posture is needed to avoid distracting muscle tension. Patients can try sitting, lying down, or the yoga “lotus” position. In any case, the pa- tient should feel comfortable and relaxed.

THE BOTTOM LINE Patients bring an endless variety of religious and spiritual practices with them when they visit the doctor or enter a hospital or long-term care facility, and not all of them stem from a recognized, organized religion. To offer optimal, patient-centered care, practitioners must ask the right questions and learn what patients are turning to for meaning or as a guide to their health care decisions.

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